Self-report of gastrointestinal side effects after bariatric surgery

Is Sigstad's score really capable of detecting post-surgical late dumping syndrome?

BACKGROUND

This clinical trial explores the Sigstad score for late dumping syndrome in postoperative patients who have undergone sleeve gastrectomy (SG) or One Anastomosis Gastric Bypass (OAGB). The aims of this study are to investigate the correlations with late dumping syndrome, to evaluate the reliability and validity of the Sigstad score and to discuss a modified scoring system.

METHODS

The study was conducted at the Obesity Center of the Westküstenklinikum Heide and included 271 patients. Data collection involved conducting interviews, diet diaries and measuring blood glucose levels. Non-parametric tests, logistic regression and McDonald's Omega were the selected statistical approaches.

RESULTS

Body Mass Index (BMI) decreased over time (-9.67 kg/m2 at 4 months, -15.58 kg/m2 at 12 months). Preoperatively, the Sigstad score exhibited the highest value, and no occurrences of late dumping syndrome were observed. No significant differences were found in BMI concerning late dumping syndrome or Sigstad score among postoperative patients. Postoperative patients experienced an increase in gastrointestinal symptoms. The reliability test showed a McDonald's omega value of 0.509. The analysis conducted through binary logistic regression indicated dizziness as a significant predictor of late dumping syndrome; however, this finding did not hold up after performing Bonferroni correction.

CONCLUSION

The Sigstad score is not a reliable or valid method for detecting late dumping syndrome after surgery for obesity and metabolic disorders. It is necessary to have alternatives that use objective measures and assess the quality of life, and that these alternatives be validated in large patient cohorts.

Mechanism of Acupuncture in Treating Obesity: Advances and Prospects

Obesity is a common metabolic syndrome that causes a significant burden on individuals and society. Conventional therapies include lifestyle interventions, bariatric surgery, and pharmacological therapies, which are not effective and have a high risk of adverse events. Acupuncture is an effective alternative for obesity, it modulates the hypothalamus, sympathetic activity and parasympathetic activity, obesity-related hormones (leptin, ghrelin, insulin, and CCK), the brain-gut axis, inflammatory status, adipose tissue browning, muscle blood flow, hypoxia, and reactive oxygen species (ROS) to influence metabolism, eating behavior, motivation, cognition, and the reward system. However, hypothalamic regulation by acupuncture should be further demonstrated in human studies using novel techniques, such as functional MRI (fMRI), positron emission tomography (PET), electroencephalogram (EEG), and magnetoencephalography (MEG). Moreover, a longer follow-up phase of clinical trials is required to detect the long-term effects of acupuncture. Also, future studies should investigate the optimal acupuncture therapeutic option for obesity. This review aims to consolidate the recent improvements in the mechanism of acupuncture for obesity as well as discuss the future research prospects and potential of acupuncture for obesity.

Postoperative Dumping Syndrome, Health-Related Quality of Life, Anxiety, Depression, and Eating Disturbances: Results of a Longitudinal Obesity Surgery Study

INTRODUCTION

Given the lack of research on the relationship of post-surgery dumping syndrome and eating disturbances, the purpose of the present longitudinal study was to investigate whether dumping after obesity surgery is associated with pre-/postoperative eating disorder symptoms or addiction-like eating beyond the type of surgery, gender, health-realted quality of life (HRQoL) and anxiety/depressive symptoms.

METHODS

The study included 220 patients (76% women) before (t0) and 6 months after (t1) obesity surgery (sleeve gastrectomy [n = 152], Roux-en-Y gastric bypass [n = 53], omega loop gastric bypass [n = 15]). The Sigstad Dumping Score was used to assess post-surgery dumping syndrome. Participants further answered the Eating Disorder Examination Questionnaire (EDE-Q), Yale Food Addiction Scale 2.0 (YFAS 2.0), Short-Form Health Survey (SF-12), and Hospital Anxiety and Depression Scale (HADS) at t0 and t1.

RESULTS

The point prevalence of symptoms suggestive of post-surgery dumping syndrome was 33%. Regression analyses indicate an association of dumping with surgical procedure (bypass), female gender, reduced HRQoL, more anxiety/depressive symptoms, and potentially with binge eating but not with eating disorder symptoms in general or with addiction-like eating.

CONCLUSION

The current study failed to show a close relationship between the presence of self-reported dumping syndrome and eating disorder symptoms or addiction-like eating following obesity surgery. Further studies with longer follow-up periods should make use of clinical interviews to assess psychosocial variables and of objective measures to diagnose dumping in addition to standardized self-ratings.

Current Role and Potential of Polymeric Biomaterials in Clinical Obesity Treatment

The rise of obesity and associated fatal diseases has taken a massive toll worldwide. Despite the existing pharmaceuticals and bariatric surgeries, these approaches manifest limited efficacy or accompany various side effects. Therefore, researchers seek to facilitate the prolonged and specific delivery of therapeutics. Or else, to mimic the essential part of "gastric bypass" by physically blocking excessive absorption via less invasive methods. To achieve these goals, polymeric biomaterials have gained tremendous interest recently. They are known for synthesizing hydrogels, microneedle patches, mucoadhesive coatings, polymer conjugates, and so forth. In this Review, we provide insights into the current studies of polymeric biomaterials in the prevention and treatment of obesity, inspiring future improvements in this regime of study.

Dumping syndrome after bariatric surgery: prevalence, pathophysiology and role in weight reduction - a systematic review

Background

Dumping syndrome is a frequent and wellknown adverse event after bariatric surgery and covers a dynamic spectrum of early and late dumping. Accelerated gastric emptying is generally considered to be the cause of gastrointestinal and vasomotor complaints. However, there is much uncertainty regarding the exact pathophysiology of dumping. It has been speculated that the syndrome is a desired consequence of bariatric surgery and contributes to more efficient weight loss, but supporting data are scarce.

Methods

A systematic search was conducted in PubMed in July-August 2021. The prevalence of dumping after the most frequently performed bariatric procedures was analyzed, as well as underlying pathophysiology and its role in weight reduction.

Results

Roux-en-Y gastric bypass (RYGB) is associated with the highest postoperative prevalence of dumping. The fast transit induces neurohumoral changes which contribute to an imbalance between postprandial glucose and insulin levels, resulting in hypoglycemia which is the hallmark of late dumping. Early dumping can, when received in a positive way, become a tool to maintain a strict dietary pattern, but no significant relationship to the degree of weight loss has been shown. However, late dumping is detrimental and promotes overall higher caloric intake.

Conclusion

Dumping syndrome is common after bariatric surgery, especially after RYGB. The pathophysiology is complex and ambiguous. Currently available data do not support dumping as a necessary condition to induce weight loss after bariatric surgery.

Regulation of appetite-related neuropeptides by Panax ginseng: A novel approach for obesity treatment

Obesity is a primary factor provoking various chronic disorders, including cardiovascular disease, diabetes, and cancer, and causes the death of 2.8 million individuals each year. Diet, physical activity, medications, and surgery are the main therapies for overweightness and obesity. During weight loss therapy, a decrease in energy stores activates appetite signaling pathways under the regulation of neuropeptides, including anorexigenic [corticotropin-releasing hormone, proopiomelanocortin (POMC), cholecystokinin (CCK), and cocaine- and amphetamine-regulated transcript] and orexigenic [agouti-related protein (AgRP), neuropeptide Y (NPY), and melanin-concentrating hormone] neuropeptides, which increase food intake and lead to failure in attaining weight loss goals. Ginseng and ginsenosides reverse these signaling pathways by suppressing orexigenic neuropeptides (NPY and AgRP) and provoking anorexigenic neuropeptides (CCK and POMC), which prevent the increase in food intake. Moreover, the results of network pharmacology analysis have revealed that constituents of ginseng radix, including campesterol, beta-elemene, ginsenoside Rb1, biotin, and pantothenic acid, are highly correlated with neuropeptide genes that regulate energy balance and food intake, including ADIPOQ, NAMPT, UBL5, NUCB2, LEP, CCK, GAST, IGF1, RLN1, PENK, PDYN, and POMC. Based on previous studies and network pharmacology analysis data, ginseng and its compounds may be a potent source for obesity treatment by regulating neuropeptides associated with appetite.

The gastro-jejunal anastomosis site influences dumping syndrome and weight regain in patients with obesity undergoing Laparoscopic Roux-en-Y Gastric Bypass

PURPOSE

The Laparoscopic Roux-en-Y Gastric Bypass (LRYGB) is an effective weight loss procedure. The gastro-jejunal (GJ) anastomosis required can be performed on the anterior or posterior gastric pouch wall. No studies have compared these variants in terms of efficacy and onset of dumping syndrome (DS) and weight regain (WR). We aimed at assessing the prevalence of DS in relation to the site of anastomosis together with identifying prognostic factors of DS and WR.

METHODS

Patients who had undergone LRYGB with anterior (AGJ) or posterior (PGJ) anastomosis in 2010-2019 were retrospectively analyzed. We collected demographic data, medical history and the prevalence of DS evaluated through the Sigstad Score, together with WR data.

RESULTS

213 patients were enrolled, of which 51.6% had an AGJ and 48.4% had a PGJ. The mean follow-up time was 81 ± 18 and 27 ± 13 months in the AGJ and PGJ group, respectively (p < 0.0001). Excess weight loss was 77.59% and 94.13% in patients with AGJ and PGJ, respectively (p < 0.001). WR rate was 16% and 4% in the AGJ and PGJ population, respectively (p < 0.001). DS prevalence was 38% and 76% in the AGJ and the PGJ population, respectively (p < 0.0001). The site of anastomosis was identified as an independent predictor of DS (OR5.15; 95% CI 2.82-9.41; p < 0.0001) and WR (OR5.31; 95% CI 2.32-12.15; p < 0.0001). Obesity-related complications significantly improved after surgery independent of the anastomosis site.

CONCLUSION

LRYGB is effective in determining long-term weight loss and improvement of complications. AGJ is associated with lower prevalence of DS but more frequent WR. The anastomosis site is a factor to be considered when performing LRYGB.

LEVEL OF EVIDENCE

Level V, cross-sectional descriptive study.

Dietary macro- and micro-nutrients intake adequacy at 6th and 12th month post-bariatric surgery

BACKGROUND

Bariatric surgery (BS) is considered as an effective solution to control morbid obesity. Food restrictions resulting from the operation may decrease dietary nutrient intakes, particularly during the first year after BS. This study mainly aimed to assess the adequacy of dietary nutrient intakes at 6th and 12th month after BS.

METHOD

Of the severely obese participants in the Tehran obesity treatment study in 2015-2016, 58 patients undergoing Roux-En-Y gastric bypass (N = 16) or sleeve gastrectomy (N = 42) were selected from Tehran Obesity Treatment Center. To assess the patients' dietary intake, a three-day, 24-h dietary recall was obtained on three unscheduled days (two non-consecutive weekdays and one weekend day) at 6th and 12th month after BS. To evaluate the adequacy of nutrient intake, the patients' intakes were compared to the current dietary reference intakes (DRIs), including estimated average requirements (EAR) or Adequate Intakes (AI).

RESULTS

The mean age of the participants (71% women) undergoing BS was 37 ± 8 years. Anthropometric parameters significantly decreased at the 12th month after BS. The percentage of energy from carbohydrate intake increased significantly between the 6th and 12th month after BS (P = 0.04). The mean ± SD of protein intake was lower than the recommended dosage with a dramatic decrease from 45 ± 30 to 31 ± 15 (g/day) between the two intervals (P = 0.001). The mean intake of saturated fatty acid (SFA) decreased dramatically (P < 0.001) from 6 to 12 month; however, the median intake of n3-polyunsaturated fatty acid (n3-PUFA) intake increased (P = 0.02). None of the participants showed nutrient intake adequacy in terms of biotin, fat soluble vitamins, pantothenic acid, potassium, and zinc. Moreover, less than 10% of the participants showed nutrient intake adequacy in terms of folate, magnesium, manganese, and calcium according to DRIs during the both intervals after BS.

CONCLUSION

Bariatric surgery can reduce dietary intakes, which is more obvious 12 months after the surgery. Out of 21 micronutrients, nearly all could not met the EAR and were received < 50%, also had significant reduction from the 6th to12th month after surgery.

Using Bayesian Networks to Predict Long-Term Health-Related Quality of Life and Comorbidity after Bariatric Surgery: A Study Based on the Scandinavian Obesity Surgery Registry

Previously published literature has identified a few predictors of health-related quality of life (HRQoL) after bariatric surgery. However, performance of the predictive models was not evaluated rigorously using real world data. To find better methods for predicting prognosis in patients after bariatric surgery, we examined performance of the Bayesian networks (BN) method in predicting long-term postoperative HRQoL and compared it with the convolution neural network (CNN) and multivariable logistic regression (MLR). The patients registered in the Scandinavian Obesity Surgery Registry (SOReg) were used for the current study. In total, 6542 patients registered in the SOReg between 2008 and 2012 with complete demographic and preoperative comorbidity information, and preoperative and postoperative 5-year HROoL scores and comorbidities were included in the study. HRQoL was measured using the RAND-SF-36 and the obesity-related problems scale. Thirty-five variables were used for analyses, including 19 predictors and 16 outcome variables. The Gaussian BN (GBN), CNN, and a traditional linear regression model were used for predicting 5-year HRQoL scores, and multinomial discrete BN (DBN) and MLR were used for 5-year comorbidities. Eighty percent of the patients were randomly selected as a training dataset and 20% as a validation dataset. The GBN presented a better performance than the CNN and the linear regression model; it had smaller mean squared errors (MSEs) than those from the CNN and the linear regression model. The MSE of the summary physical scale was only 0.0196 for GBN compared to the 0.0333 seen in the CNN. The DBN showed excellent predictive ability for 5-year type 2 diabetes and dyslipidemia (area under curve (AUC) = 0.942 and 0.917, respectively), good ability for 5-year hypertension and sleep apnea syndrome (AUC = 0.891 and 0.834, respectively), and fair ability for 5-year depression (AUC = 0.750). Bayesian networks provide useful tools for predicting long-term HRQoL and comorbidities in patients after bariatric surgery. The hybrid network that may involve variables from different probability distribution families deserves investigation in the future.

Prevalence of Dumping Syndrome After Laparoscopic Sleeve Gastrectomy and Comparison with Laparoscopic Roux-en-Y Gastric Bypass

BACKGROUND

Dumping syndrome is a well-known side effect of laparoscopic gastric bypass (LRYGB), and it is commonly believed that dumping syndrome is less likely to occur after laparoscopic sleeve gastrectomy (LSG), due to the preservation of the pyloric sphincter. However, it is not uncommon for patients undergoing LSG at our center to report symptoms suggestive of dumping syndrome.

OBJECTIVE

To assess the prevalence of symptoms of dumping syndrome after LSG compared with LRYGB.

SETTING

A single surgical group at a high-volume (700 cases per year) Bariatric and Metabolic Surgery Center of Excellence.

METHODS

One thousand four hundred seventy-one LRYGB (366) and LSG (1105) patients received a questionnaire to assess symptoms of dumping syndrome, utilizing a modified version of the Sigstad scoring system. Dumping syndrome was considered to be present when the questionnaire score exceeded a threshold value.

RESULTS

A total of 360 responses were received (249 LSG, 111 LRYGB). 26.5% (66) LSG and 41.4% (46) LRYGB exceeded the threshold for dumping syndrome (p < 0.01). 84.8% (56) LSG and 84.7% (39) LRYGB reported early dumping syndrome (p > 0.05). Thirty-six percent (24) LSG and 28% (13) LRYGB reported late dumping syndrome (p > 0.05). Twenty-seven percent (62) LSG and 44.4% (44) LRYGB reported at least one symptom of dumping syndrome with sweets (p < 0.05). 34.3% (85) LSG and 35.5% (39) LRYGB reported symptoms when drinking with or within 30 min of a meal (p > 0.05). 14.5% (36) LSG and 17.3% (19) LRYGB reported symptoms after alcohol consumption (p > 0.05).

CONCLUSION

Dumping syndrome after LSG is prevalent but has not been widely reported. This finding may impact clinicians and patients in their choice of procedure and has relevance in post-operative education and care.

Role of Functional Biomarkers to Identify Early Vitamin B12 Deficiency in Patients with Sleeve Gastrectomy: A Cross-Sectional Study

Background and objectives: Although laparoscopic sleeve gastrectomy (LSG) is effective for obesity management, postoperative vitamin B12 (B12) deficiency is of major concern. In this cross-sectional study, we assessed the levels of B12 and its related functional biomarkers, namely, total homocysteine (tHcy), methylmalonic acid (MMA), folate, methylcitric acid (MCA), and hemoglobin (Hb), in one-year postoperative LSG patients and matched controls. Materials and Methods: Plasma B12, tHcy, MMA, folate, and MCA were measured in matched controls (n = 66) and patients (n = 71) using validated liquid chromatography-tandem mass spectrometry techniques and protocols in the United Arab Emirates (UAE). Results: The median B12 concentration in patients (177 pmol/L) was significantly lower (p < 0.001) than in the controls (334.7 pmol/L). The tHcy and MMA levels were significantly increased (p < 0.001 and p = 0.011, respectively) and folate levels were significantly decreased (p = 0.001) in the LSG patients compared to the controls. Interestingly, no significant difference in MCA levels were observed between the two groups. The levels of tHcy and MMA were concomitantly increased with the decreased folate levels in postoperative LSG patients when compared with the controls. The Hb levels were significantly lower in males and females in the patient group compared with those in the control group, respectively (p = 0.005 and p = 0.043). Conclusions: This is the first report of serum levels of B12 and its functional biomarkers in postoperative LSG patients among a local population from the UAE. Our findings revealed significant alterations of the B12 biomarkers, total B12, MMA, and tHcy in one-year postoperative LSG patients.

Associations between perceived somatic symptoms and mental health after Roux-en-Y gastric bypass: a 3-year prospective cohort study

BACKGROUND

Attention to and interpretation of symptoms are influenced by psychologic and contextual factors. Preoperative anxiety, and to some extent depression, has been found to predict the perceived impact of somatic symptoms 1 year after Roux-en-Y gastric bypass. Postoperative changes in negative affect may possibly both influence and be influenced by the perception of somatic symptoms.

OBJECTIVES

This study aimed to explore whether preoperative anxiety and depressive symptoms correlated with perceived impact of somatic symptoms 3 years after Roux-en-Y gastric bypass. Second, we aimed to examine the 3-year trajectory of depressive and anxiety symptoms, and their interaction with perceived somatic symptoms postoperatively.

SETTING

University hospital.

METHODS

Presurgery, 1-, and 3-year postsurgery data were collected from 169 participants (62.4% follow-up). Anxiety and depressive symptoms were assessed at all time points. The participants reported the degree of perceived impact of various somatic symptoms 1 and 3 years after surgery. A cross-lagged, autoregressive regression analysis was employed to examine the mutual interaction of trajectories over the follow-up period.

RESULTS

Fatigue (30.8%) and dumping (23.7%) were common high-impact symptoms 3 years postoperatively. Higher baseline anxiety was associated with higher impact of fatigue, pain, and diarrhea, while depressive mood was related to higher impact of diarrhea at 3-year follow-up. Higher anxiety/depression symptoms were bidirectionally related to higher perceived total symptom impact at both 1 and 3 years postoperatively, controlling for percent total weight loss. Higher perceived impact of somatic symptom burden at 1 year after surgery predicted a significant increase in depressive symptoms the next 2 years.

CONCLUSION

Baseline anxiety was associated with higher perceived impact of several somatic symptoms 3 years after Roux-en-Y gastric bypass. Higher total symptom burden (pain, fatigue, dumping, diarrhea, and vomiting) at 1 year after surgery predicted increase in depression over the next 2 years. The results underscore the importance of managing somatic symptoms after surgery to prevent patients' distress.

Mentorship Programs in Bariatric Surgery Reduce Perioperative Complication Rate at Equal Short-Term Outcome-Results from the OPTIMIZE Trial

OBJECTIVES

The aim of this study was to determine the efficacy of coaching on outcome in low volume centers of excellence and to evaluate the influence of mentorship programs on the center development.

BACKGROUND

The number of bariatric procedures has increased steadily in the last years. Providing nationwide bariatric care on a high professional level needs structures to train and guide upcoming centers and ensure high quality in patient care.

METHODS

A prospective multicentered, observational study including laparoscopic sleeve gastrectomies (SG) and Roux-en-Y gastric bypass (RYGB) procedures was performed. Twelve emerging bariatric centers were coached by five experienced bariatric centers. Surgeons of the mentor centers gave guidance on pre- and postsurgical management of their patients including complications and proctored the first interventions. The results were compared regarding operative outcomes, percentage of excess weight loss, complications, and resolution of comorbidities.

RESULTS

A total of 214 of 293 patients (73.0%) completed the study. The most frequently reported complications were wound infection (4.4%), disorder of emptying stomach/new reflux (2.4%), anastomotic leaks, intra-abdominal secondary hemorrhage, and dumping syndrome (2.0% each). The mortality rate was zero. We found no difference in overall complication rates or resolution of obesity-related comorbidities when comparing experienced surgeons with less experienced surgeons.

CONCLUSIONS

Our results suggest that under the conditions of the practices of this study, coaching and mentoring were associated with comparable outcomes both in experienced and emerging centers. In addition, mentorship programs ensure equal outcome quality in terms of improvement of obesity-associated comorbidities.

TRIAL REGISTRATION

NCT Number: NCT01754194 .

Bariatric surgery and type 2 diabetes

Type 2 diabetes is primarily managed with lifestyle modifications, self-monitoring of blood glucose, and medication. The goal is to maintain A1C less than 7% in most patients and prevent damage to other organs such as the kidneys and heart. Patients who are obese and cannot achieve normal blood glucose levels despite diet, exercise, and multiple medications may be considered for bariatric surgery. The Roux-en-Y gastric bypass and laparoscopic sleeve gastrectomy have been shown to improve A1C, reduce weight, and reduce the number of medications patients need for diabetes management. Comorbidities such as hyperlipidemia and hypertension also may improve. This article describes types of bariatric surgery, proper selection of surgical candidates, patient education, and the postoperative patient management necessary for long-term success in improving blood glucose control.

Saliva with reduced calcium and phosphorous concentrations: Effect on erosion dental lesions

OBJECTIVES

To investigate whether saliva formulations with reduced calcium (Ca) and inorganic phosphorous (Pi) concentration would affect dental erosion caused by hydrochloric acid (HCl).

METHODS

Enamel and root dentine bovine slabs were embedded, polished, and measured for surface Knoop microhardness (SMH). After reference areas were created, specimens were exposed to HCl solution (0.01 M; pH 2; 120 s) and immersed in artificial salivas (6 hr) containing three different Ca/Pi concentrations (n = 15), which simulate serum conditions of normo-, mild, or severe hypocalcemia. The control group was immersed in Ca/Pi-free saliva. The study protocol was carried out 2×/day for 5 days. Surface loss of enamel and root dentine was assessed using an optical profilometer, and SMH was remeasured for enamel.

RESULTS

One-way analysis of variance (p < .001) and Tukey's test showed that enamel loss in groups subjected to artificial salivas that simulated mild or severe hypocalcemia did not differ from that resembling normocalcemia. %SMH was lower when saliva was mildly and normally concentrated in Ca/Pi (p < .001). Root dentine loss was higher in saliva simulating severe hypocalcemia than in those referring to mild, hypo-, and normocalcemia.

CONCLUSIONS

Depending on the dental substrate, salivary formulations resembling serum hypocalcemia affected surface loss due to erosion and rehardening thereof.

Surgery-related gastrointestinal symptoms in a prospective study of bariatric surgery patients: 3-year follow-up

BACKGROUND

Having accurate information on bariatric surgery-related gastrointestinal (GI) symptoms is critical for patient care.

OBJECTIVE

To report on surgery-related GI symptoms over the first 3 years following Roux-en-Y gastric bypass and laparoscopic adjustable gastric band.

SETTING

Three academic medical centers in the United States.

METHODS

As a substudy of the Longitudinal Assessment of Bariatric Surgery Consortium, 183 participants (pre-surgery median body mass index = 45.1 kg/m²; median age = 46 yr; 83.1% female). completed the Eating Disorder Examination-Bariatric Surgery Version interview at≥1 annual assessment. Patients self-reported frequency of dysphagia, dumping syndrome, and spontaneous vomiting.

RESULTS

Prevalence of dysphagia at least once weekly decreased post-laparoscopic adjustable gastric band surgery from 43.9% (95% confidence interval [CI], 32.2-55.6) in year 1 to 27.5% (95% CI, 15.2-39.9) in year 3 (P = .02). Dysphagia and dumping at least once weekly also appeared to decrease in years 1-3 post-Roux-en-Y gastric bypass (i.e., from 16.7% [95% CI, 9.4-24.1] to 10.9% [95% CI, 4.0-17.8] and from 9.9% [95% CI, 4.3-15.5] to 6.3% [95% CI, 1.7-10.9], respectively), but power was limited to evaluate trends. Vomiting at least once weekly was rare (<6%) in years 1-3 following both procedures. Controlling for potential confounders and surgical procedure, loss of control eating at least once weekly was associated with higher risk of at least once weekly dysphagia (relative risk = 2.01, 95% CI, 1.36-2.99, P = .001).

CONCLUSIONS

The prevalence of bariatric surgery-related GI symptoms appears to decrease across follow-up. Symptoms were associated with loss of control eating, suggesting a target for clinical intervention.

Gastrointestinal Transcriptomic Response of Metabolic Vitamin B12 Pathways in Roux-en-Y Gastric Bypass

OBJECTIVES

Vitamin B12 (B12) deficiency after Roux-en-Y gastric bypass (RYGB) is highly prevalent and may contribute to postoperative complications. Decreased production of intrinsic factor owing to gastric fundus removal is thought to have a major role, but other components of B12 metabolism may also be affected. We evaluated changes in the expression levels of multiple B12 pathway-encoding genes in gastrointestinal (GI) tissues to evaluate the potential roles in contributing to post-RYGB B12 deficiency.

METHODS

During double-balloon enteroscopy, serial GI biopsies were collected from 20 obese women (age, 46.9±6.2 years; body mass index, 46.5±5.3 kg/m2) with adult-onset type 2 diabetes (fasting plasma glucose ≥126 mg/dl; hemoglobin A1c≥6.5%) before and, at the same site, 3 months after RYGB. Gene expression levels were assessed by the Affymetrix Human GeneChip 1.0 ST microarray. Findings were validated by real-time quantitative PCR (RT-qPCR).

RESULTS

Gene expression levels with significant changes (P≤0.05) included: transcobalamin I (TCN1) in remnant (-1.914-fold) and excluded (-1.985-fold) gastric regions; gastric intrinsic factor (GIF) in duodenum (-0.725-fold); and cubilin (CUBN) in duodenum (+0.982-fold), jejunum (+1.311-fold), and ileum (+0.685-fold). Validation by RT-qPCR confirmed (P≤0.05) observed changes for TCN1 in the remnant gastric region (-0.132-fold) and CUBN in jejunum (+2.833-fold).

CONCLUSIONS

RYGB affects multiple pathway-encoding genes that may be associated with postoperative B12 deficiency. Decreased TCN1 levels seem to be the main contributing factor. Increased CUBN levels suggest an adaptive genetic reprogramming of intestinal tissue aiming to compensate for impaired intestinal B12 delivery.

Ghrelin, CCK, GLP-1, and PYY(3-36): Secretory Controls and Physiological Roles in Eating and Glycemia in Health, Obesity, and After RYGB

The efficacy of Roux-en-Y gastric-bypass (RYGB) and other bariatric surgeries in the management of obesity and type 2 diabetes mellitus and novel developments in gastrointestinal (GI) endocrinology have renewed interest in the roles of GI hormones in the control of eating, meal-related glycemia, and obesity. Here we review the nutrient-sensing mechanisms that control the secretion of four of these hormones, ghrelin, cholecystokinin (CCK), glucagon-like peptide-1 (GLP-1), and peptide tyrosine tyrosine [PYY(3-36)], and their contributions to the controls of GI motor function, food intake, and meal-related increases in glycemia in healthy-weight and obese persons, as well as in RYGB patients. Their physiological roles as classical endocrine and as locally acting signals are discussed. Gastric emptying, the detection of specific digestive products by small intestinal enteroendocrine cells, and synergistic interactions among different GI loci all contribute to the secretion of ghrelin, CCK, GLP-1, and PYY(3-36). While CCK has been fully established as an endogenous endocrine control of eating in healthy-weight persons, the roles of all four hormones in eating in obese persons and following RYGB are uncertain. Similarly, only GLP-1 clearly contributes to the endocrine control of meal-related glycemia. It is likely that local signaling is involved in these hormones' actions, but methods to determine the physiological status of local signaling effects are lacking. Further research and fresh approaches are required to better understand ghrelin, CCK, GLP-1, and PYY(3-36) physiology; their roles in obesity and bariatric surgery; and their therapeutic potentials.

Early dumping syndrome is not a complication but a desirable feature of Roux-en-Y gastric bypass surgery

Early dumping syndrome after gastric bypass surgery due to rapid delivery of hyperosmolar nutrients into the bowel causing intense symptoms is often described as a complication. Twelve patients, mean age 47 years, were interviewed approximately 9 years post-operation. The interviews were audiotaped and transcribed verbatim, followed by an inductive content analysis to reveal patients' experience of the dumping syndrome. The core category 'Dumping syndrome is a positive consequence of Roux-en-Y gastric bypass surgery and a tool to control food intake' was identified based on the following four sub-categories: (i) 'The multidimensional emergence and effects of dumping syndrome', (ii) 'Dumping syndrome as something positive although unpleasant', (iii) 'Developing coping mechanisms and ingenious strategies' and (iv) 'My own fault if I expose myself to dumping syndrome'. From the patients' perspective, dumping syndrome gives control over food intake; although the symptoms were unpleasant, patients considered dumping syndrome as a positive protection against over-consumption. Hence, healthcare professionals should not present dumping syndrome as a complication but rather as an aid to control eating behaviour and excessive food intake.

Structured dietary intervention to facilitate weight loss after bariatric surgery: A randomized, controlled pilot study

OBJECTIVE

To evaluate the potential utility of a structured dietary intervention to assist bariatric surgery patients with weight management.

METHODS

Participants who underwent Roux-en-Y gastric bypass surgery 1 year previously were randomly assigned to a structured dietary intervention incorporating portion-controlled foods (intervention, n = 20) or a comparison group (control, n = 20). Both groups received instruction in behavioral weight loss (one 60-min session) followed by four monthly coaching telephone calls. Assessments were conducted at baseline, 4 months (post-intervention), and 6 months.

RESULTS

Participants were 85% female and 80% White. Average age was 46.9 (11.1) years, and body mass index was 31.3 (5.4) kg/m(2) at enrollment. Percent weight change from enrollment was significantly greater for intervention compared with control participants at 4 months [-4.56% vs. -0.13%, t(30)  = -3.29, P = 0.003] and 6 months [-4.07% vs. -0.14%, t(31)  = -2.03, P = 0.05]. Change in average daily calorie intake was greater among intervention compared with control [-108 vs. 116, t(30)  = -2.01, P = 0.05] at 4 months only.

CONCLUSIONS

A structured dietary intervention increased weight loss and reduced calorie intake when initiated 1 year following Roux-en-Y gastric bypass. This approach holds promise for optimizing postsurgery lifestyle change.

Cirurgia bariátrica e transtornos alimentares: uma revisão integrativa

RESUMO Objetivo Realizar revisão sobre transtornos alimentares e comportamentos alimentares transtornados relacionados à cirurgia bariátrica. Métodos Revisão integrativa da literatura nas bases de dados PubMed, Lilacs, Bireme, portal SciELO com descritores indexados com critérios de inclusão: oferecer dado sobre a presença ou frequência de transtorno alimentar e/ou comportamentos alimentares disfuncionais previamente e/ou após a cirurgia. Resultados Foram selecionados 150 estudos (14 nacionais e 136 internacionais): 80,6% eram com avaliação de pacientes pré-/pós-cirúrgicos; 12% eram estudos de caso e 7,3% eram estudos de revisão. Diferentes instrumentos foram usados para avaliação, principalmente o Questionnaire on Eating and Weight Patterns, a Binge Eating Scale e Eating Disorders Examination Questionnaire. A compulsão alimentar foi o comportamento mais avaliado, com frequências/prevalências variando de 2% a 94%; no caso do transtorno da compulsão alimentar as frequências/prevalências variaram de 3% a 61%. Houve também a descrição de anorexia e bulimia nervosa, síndrome da alimentação noturna e comportamento beliscador. Alguns estudos apontam melhora dos sintomas no pós-cirúrgico e/ou seguimento enquanto outros apontam surgimento ou piora dos problemas. Conclusão Apesar da variabilidade entre métodos e achados, comportamentos alimentares disfuncionais são muito frequentes em candidatos à cirurgia bariátrica e podem ainda surgir ou piorar após a intervenção cirúrgica. Profissionais de saúde devem considerar de maneira mais cuidadosa tais problemas neste público, dadas às consequências para o resultado cirúrgico e qualidade de vida.

Prevalence, severity, and predictors of symptoms of dumping and hypoglycemia after Roux-en-Y gastric bypass

BACKGROUND

Roux-en-Y gastric bypass (RYGB) results in pronounced weight loss in morbidly obese patients but may also cause adverse effects like early dumping and hypoglycemia. Prevalence data on these complications and their potential predictors are sparse.

OBJECTIVE

To assess the prevalence and possible predictors of early dumping and hypoglycemia in a population-based cohort of RYGB patients.

SETTING

University Hospital, Denmark.

DESIGN

A questionnaire survey was performed in the Central Denmark Region including RYGB-operated patients (years 2006-2011, n = 2238) and a nonoperated comparison cohort (n = 89). The Dumping Rating Scale and the Edinburgh Hypoglycemia Scoring System, together with demographic and clinical characteristics, were used, and possible predictors were examined by logistic regression.

RESULTS

The response rate was 64% (1429/2238). In total, 9.4% (134/1429) and 6.6% (95/1429) experienced moderate or severe symptoms of early dumping and hypoglycemia, respectively, which were significantly higher than in the comparison cohort. Because 3.4% (95% CI: 2.5-4.4) of the RYGB group experienced both early dumping and hypoglycemia, the total prevalence of 1 or both conditions was 12.6 (95% CI 10.9-14.4). Possible predictors for both conditions were body mass index (BMI)<25 kg/m² (odds ratio [OR] 1.70 (95% CI: 0.98-2.95) and OR 1.60 (95% CI: .83-3.06), respectively) compared with patients with BMI 25-30 kg/m². Younger age seemed to increase the risk of both conditions (<35 yr: OR 1.75 (95% CI: 1.11-2.75) and OR .59 (95% CI: .93-2.72), respectively) compared with patients>45 years.

CONCLUSION

Symptoms of early dumping and hypoglycemia were rather common with a prevalence of 1 or both conditions of 12.6% after RYGB. Predictors included younger age and a lower BMI.

Metabolomics Study of Roux-en-Y Gastric Bypass Surgery (RYGB) to Treat Type 2 Diabetes Patients Based on Ultraperformance Liquid Chromatography-Mass Spectrometry

Roux-en-Y gastric bypass (RYGB) is one of the most effective treatments for long-term weight loss and diabetes remission; however, the mechanisms underlying these changes are not clearly understood. In this study, the serum metabolic profiles of 23 remission and 12 nonremission patients with type 2 diabetes mellitus (T2DM) were measured at baseline, 6- and 12-months after RYGB. A metabolomics analysis was performed based on ultra-performance liquid chromatography-mass spectrometry. Clinical improvements in insulin sensitivity, energy metabolism, and inflammation were related to metabolic alterations of free fatty acids (FFAs), acylcarnitines, amino acids, bile acids, and lipids species. Differential metabolic profiles were observed between the two T2DM subgroups, and patients with severity fat accumulation and oxidation stress may be more suitable for RYGB. Baseline levels of tryptophan, bilirubin, and indoxyl sulfate measured prior to surgery as well as levels of FFA 16:0, FFA 18:3, FFA 17:2, and hippuric acid measured at 6 months after surgery best predicted the suitability and efficacy of RYGB for patients with T2DM. These metabolites represent potential biomarkers that may be clinically helpful in individualized treatment for T2DM patients by RYGB.

Psychosocial Interventions Pre and Post Bariatric Surgery

Despite positive results overall, a substantial number of patients experience poor long-term outcomes following bariatric surgery. One reason for variability in weight loss may be difficulty in making and sustaining changes in dietary intake and physical activity; post-surgery binge eating has also been associated with poorer weight outcomes. In this paper, we review available evidence on adjunctive psychosocial interventions for bariatric surgery patients. Although the literature is limited, evidence suggests that bariatric surgery patients may benefit from a comprehensive approach targeting diet, activity and psychological factors. We think the optimal time to initiate adjunctive intervention is after surgery, but before significant weight regain has occurred. Adaptive interventions incorporating advances in technology may prove to be effective for promoting behavioural self-management and psychosocial adjustment following bariatric surgery. For some patients, pharmacotherapy and reoperation may also play a role in a personalized approach to post-surgery care.

Eating Disorders and Problematic Eating Behaviours Before and After Bariatric Surgery: Characterization, Assessment and Association with Treatment Outcomes

Accumulating evidence suggests that bariatric surgery candidates are likely to present with eating disorders (EDs) and/or problematic eating behaviours (EBs), and research suggests that these problems may persist or develop after bariatric surgery. While there is growing evidence indicating that EDs and EBs may impact bariatric surgery outcomes, the definitions and assessment methods used lack consensus, and findings have been mixed. The aims of this paper were (1) to summarize the existing literature on pre‐operative and post‐operative EDs and problematic EBs; (2) to discuss the terms, definitions and assessment measures used across studies; and (3) to consider the extent to which the presence of these problems impact surgery outcomes. We highlight the importance of investigators utilizing consistent definitions and assessment methodologies across studies. © 2015 The Authors. European Eating Disorders Review published by Eating Disorders Association and John Wiley & Sons Ltd.

Preoperative lifestyle intervention in bariatric surgery: a randomized clinical trial

BACKGROUND

Studies on the impact of presurgery weight loss and lifestyle preparation on outcomes following bariatric surgery are needed.

OBJECTIVE

To evaluate whether a presurgery behavioral lifestyle intervention improves weight loss through a 24-month postsurgery period.

SETTING

Bariatric Center of Excellence at a large, urban medical center.

METHODS

Candidates for bariatric surgery were randomized to a 6-month behavioral lifestyle intervention or to 6 months of usual presurgical care. The lifestyle intervention consisted of 8 weekly face-to-face sessions, followed by 16 weeks of face-to-face and telephone sessions before surgery; the intervention also included 3 monthly telephone contacts after surgery. Assessments were conducted 6, 12, and 24 months after surgery.

RESULTS

Participants who underwent surgery (n = 143) were 90.2% female and 86.7% White. Average age was 44.9 years, and average body mass index was 47.5 kg/m(2) at study enrollment. At follow-up, 131 (91.6%), 126 (88.1%), 117 (81.8%) patients participated in the 6-, 12-, and 24-month assessments, respectively. Percent weight loss from study enrollment to 6 and 12 months after surgery was comparable for both groups, but at 24 months after surgery, the lifestyle group had significantly smaller percent weight loss compared with the usual care group (26.5% versus 29.5%, respectively, P = .02).

CONCLUSIONS

Presurgery lifestyle intervention did not improve weight loss at 24 months after surgery. The findings from this study raise questions about the utility and timing of adjunctive lifestyle interventions for bariatric surgery patients.